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STATE OF CALIFORN',., WATER RESOURCES CONTR BOARD <br /> F'ORM 'S': UNDERGROUND STORAGE TANK PROGRAM <br /> TANK PERMIT APPLICATION INFORMATION <br /> TANK <br /> COMPLETE A SEPARATE FORM WITH THE FOLLOWING INFORMATION FOR EACH TANK. <br /> MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑ 7 7YMA CLOSED TA„K <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE LI REMOVED <br /> FACILITY/SITE NAME WHERE TANK IS INSTALLED: 3 � � FARM TANK-YES NO ❑ c_n <br /> N <br /> 1. TANK DESCRIPTION COMPLETE ALL ITEMS-IF UNKNOWN—SO SPECIFY F'-A' <br /> A. OWNERS TANK IDR B. MANUFACTURED BY: (u <br /> C. YEAR INSTALLEDD. 0 <br /> TANK CAPACITY IN GALLONS: <br /> II. TANK CONTENTS IF(Ai),IS MARKED,COMPLETE ITEM C.IF(A.1),IS NOT MARKED,COMPLETE ITEM D. <br /> A. MOTOR VEHICLE FUEL ❑ 2 PETROLEUM B. C. ❑ 1 UNLEADED LEADED ❑ 3 DIESEL <br /> ❑ 3 CHEMICAL PRODUCT ❑ 4 OIL PRODUCT 4 GASOHOL ❑ 5 JET FUEL ❑6 AVIATION GAS <br /> ❑5 HAZARDOUS ❑ 80 EMPTY ❑95 UNKNOWN ❑ 2 WASTE ❑ 7 METHANOL ❑99 OTHER(DESCRIBE IN ITEM D,BELOW) <br /> D. IF NOT MOTOR VEHICLE FUEL,ENTER NAME OF <br /> HAZARDOUS SUBSTANCE STORED&C.A.S.R C A.S.q: <br /> Ill. TANK.CONSTRUCTION MARKONEITEMONLYINBOXA,B,C.&D <br /> A TYPE OF ❑ I DOUBLE WALLED ❑3 SINGLE WALLED WITH SXTERIOR LINER 95 UNKNOWN <br /> SYSTEM ❑2 SINGLE WALLED ❑ 4 SECONDARY CONTAINMENT ❑ 99 OTHER, <br /> ❑ 1 STEEUIRON ❑2 STAINLESS STEEL ❑3 FIBERGLASS ❑4 STEEL CND W/FIBERGLASS REINFORCED PLASTIC <br /> B.TANK <br /> ❑5 CONCRETE ❑ 6 POLYVINYLCHLORIDE ❑ 7 ALUM] UM ❑ 8 10096 METHANOL OOMPATIBLEFRP <br /> ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL UNKNOWN ❑99 OTHER <br /> C. INTERIOR ❑ I RUBBER UNED ❑ 2 ALKYD LINING ❑ 3 EPDXYLINING ❑4 PHENOUCUNING <br /> LINING ❑ 5 GLASSUNING ❑6 UNLINED ff�NKNOWN <br /> ❑ IS LINING MATERIAL COMPATIBLE WITH 100%METHANOL? ❑YES ❑NO ❑99 OTHER <br /> F <br /> OSION ❑ 1 POLYEIHLENE WRAP 2 TAROflA6PHALT ❑3 VINYL WAAP ❑ q FIBERGLASS RENFORCED PLASTIC <br /> ECTION ❑ 5 CATHODIC PROTECTION ❑91 NONEUNKNOWN ❑99 OTHER <br /> IV. PIPING INFORMATION CIRCLE A IF ABOVE GROUND, U IF UNDERGROUND,BOTH IF APPLICABLE <br /> A SYSTEM TYPE A U 1 SUCTION A U 2 PRESSURE A U 3 GRAVITY A U 91 NONE A U 5 UNKNOWN A U 99 OTHER <br /> B.CONSTRUCTION A U 1 SINGLE WALLED A U 2 DOUBLE WALLED A U 3 LINED TRENCH A U 91 NONE__A( 5 UNKNOWN A U 99 OTHER <br /> A U 1 STEEL/IRON A U 2 STAINLESSSTEEL A U 3 POLYVINYL CHLORIDE(PVC) A U 4 FIBERGLASSPIPE A U 91 NONE <br /> C.MATERIAL A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEELCLAD W/FRP A U 6 100%METHANOL COMPATIBLE FRP <br /> A U 9 GALVANIZED STEEL A 095 UNKNOWN A U 99 OTHER <br /> V. LEAK DETECTION SYSTEM CIRCLE P FOR PRIMARY,OR S FOR SECONDARY,A PRIMARY LEAK DETECTION SYSTEM MUST BE CIRCLED. <br /> u P S 1 VISUAL CHECK P S 2 INVENTORY RECONCILIATION P S 3 VADOSE WELLS P S 4 ELECTRONIC MONITOR P S 5 GROUND WATER MONITORING WELLS <br /> 1� P S 6 PRECISION TESTING P 3 7 PRESSURE TESTING 05;S 91 N P S 95 UNKNOWN P S 99 OTHER <br /> VI. INFORMATION ON TANK PERMANENTLY CLOSED IN PLACE <br /> 1. ESTIMATED DATE LAST USED(MO/YR) 2. ESTIMATED OUANPTY OFOALLONB 3. WAS TANK FILLED WITH <br /> SUBSTANCE REMAINING IN INERT MATERIAL? ❑YES [_] NO <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED S SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY X JURISDICTION B AGENCY N FACILITY ID M TANK ID B <br /> Eu <br /> CURRENT LOCAL AGENCY FACILITV�♦ APPROVED BY NAME lC ) PHONE P WITH AREA CODE <br /> PERMIT NUMBER A N If,J I` PERMITAPPROVAL DATE PPEEOMIT EXPIRATION DATE <br /> CHECK M PEgNIT AMOUNT SURCHARGE AMT. FEE CODE RECEIPT 4 BY: <br /> FORM B(6-29-66) THIS FORM MUST BE ACCOMPANIED BY A FACILITY/SITE APPLICATION, FORM 'A',UNLESS A CURRENT FORMA' HAS BEEN FILED <br /> DATA PROCESSING COPY <br />